Definition and Criteria for Diagnosing Cesarean Scar Disorder

Abstract

ImportanceApproximately 60% of women develop a uterine niche after a cesarean delivery (CD). A niche is associated with various gynecological symptoms including abnormal uterine bleeding, pain, and infertility, but there is little consensus in the literature on the distinction between the sonographic finding of a niche and the constellation of associated symptoms.ObjectiveTo achieve consensus on defining the clinical condition that constitutes a symptomatic uterine niche and agree upon diagnostic criteria and uniform nomenclature for this condition.Design, Setting, and ParticipantsA consensus based modified electronic Delphi (eDelphi) study, with a predefined Rate of Agreement (RoA) of 70% or higher. Experts were selected according to their expertise with niche-related consultations, publications, and participation in expert groups and received online questionnaires between November 2021 and May 2022.Main Outcomes and MeasuresDefinition, nomenclature, symptoms, conditions to exclude, and diagnostic criteria of an illness caused by a symptomatic uterine niche.ResultsIn total, 31 of the 60 invited experts (51.7%) participated, of whom the majority worked in university-affiliated hospitals (28 of 31 [90.3%]), specialized in benign gynecology (20 of 31 [64.5%]), and worked in Europe (24 of 31 [77.4%]). Three rounds were required to achieve consensus on all items. All participants underlined the relevance of a new term for a condition caused by a symptomatic niche and its differentiation from a sonographic finding only. Experts agreed to name this condition cesarean scar disorder, defined as a uterine niche in combination with at least 1 primary or 2 secondary symptoms (RoA, 77.8%). Defined primary symptoms were postmenstrual spotting, pain during uterine bleeding, technical issues with catheter insertion during embryo transfer, and secondary unexplained infertility combined with intrauterine fluid. Secondary symptoms were dyspareunia, abnormal vaginal discharge, chronic pelvic pain, avoiding sexual intercourse, odor associated with abnormal blood loss, secondary unexplained infertility, secondary infertility despite assisted reproductive technology, negative self-image, and discomfort during participation in leisure activities. Consensus was also achieved on certain criteria that should be met and conditions that should be excluded before making the diagnosis.Conclusions and RelevanceIn this modified Delphi study, a panel of 31 international niche experts reached consensus for the constellation of symptoms secondary to a uterine niche and named it cesarean scar disorder.

The presentation and management of cesarean scar defects: an updated review on an evolving diagnosis

“…A Delphi consensus of 31 experts from three continents proposed the term ‘Cesarean Scar Disorder (CSDi)’ to capture these symptomatic CSDs. This disorder is characterized by at least one primary, or two secondary symptoms in a patient with sonographic evidence of a uterine niche (Table 1) [10 ▪ ].…”

“…Although obstetrical sequalae such as cesarean scar ectopic pregnancies, uterine dehiscence, and placenta accreta spectrum can be associated with the presence of a CSD, the experts concluded that these issues should be reported as complications of the CSDi, as opposed to symptoms. Furthermore, there was insufficient evidence to determine whether spontaneous abortion should be considered as a symptom related to the CSDi, or an independent problem [10 ▪ ].…”

Prevalence, definition, and etiology of cesarean scar defect and treatment of cesarean scar disorder: A narrative review

“…Morris advocated calling these symptoms cesarean scar syndrome 50 . Since the term describing this condition was not unified, a task force was established to avoid confusion under these conditions 51 . This task force, which comprised experts with experience in the field, provided results using the electronic Delphi method.…”

“…However, some points must be considered during the diagnosis. First, the cause of AUB should be ruled out according to the International Federation of Gynecology and Obstetrics classification system (PALM‐COEIN) 51 . Symptoms must be confirmed in at least three menstrual cycles before diagnosis.…”

Reproductive outcomes after in vitro fertilization in women with cesarean section scar diverticulum: A retrospective study

“…Furthermore, diverticula may cause inaccessibility to the uterine cavity, causing problems during intrauterine insemination or embryo transfer. 8 Various explanations for the cause of subfertility after cesarean section have been proposed in the literature, including uterine pathology such as adenomyosis, pelvic adhesions, and women's reproductive choices, 9 but there are few reports on the effects of diverticula on fertility or assisted reproductive outcomes.…”